Catheterization and Cardiovascular Interventions 85:278–281 (2015)
Optical Coherence Tomography Imaging of the Patent Ductus Arteriosus: First Known Uses in Congenital Heart Disease James A. Hill,* MD, Guruprasad Mahadevaiah, MD, and Michael W. Jenkins, PhD Background: Angiography is used to assess ductal morphology and caliber during interventional closure of the ductus arteriosus. We are evaluating the use of optical coherence tomography (OCT) to evaluate ductal anatomy given the potential benefit of superior resolution and lower radiation. Methods: Standard angiograms were performed on two patients with patent ductus arteriosus prior to device occlusion. OCT was then used to obtain high-resolution three-dimensional vessel reconstructions. Devices were chosen based on angiographic measurements. Results: OCT resulted in excellent threedimensional anatomic definition, with elliptical narrowest lumenal measurements of 2.2 3 3.1 mm and 1.6 3 2.3 mm, respectively, compared with angiographic measurements of 2.6 and 1.4 mm. Conclusions: To our knowledge, this is the first reported use of OCT use in pediatric patients outside the coronaries, and in patients with congenital heart disease. We found OCT imaging of the PDA to be feasible, and only used a small amount of additional radiation and contrast. The three-dimensional OCT reconstructions provided additional anatomic information that could potentially improve device selection, and in both cases may have led to choosing larger devices than what was chosen based on angiography. In addition, once the technique is perfected, little or no angiography or fluoroscopy will be required to perform imaging runs, and only a small injection of contrast appears to be sufficient for vessel imaging. However, there are certain limitations to OCT imaging that are unlikely to make it the method of choice specifically for imaging the patent ductus arteriosus, but we have shown its ability to provide high resolution imaging in a relatively simple fashion which may prove useful for other purposes. VC 2014 Wiley Periodicals, Inc. Key words: OCT; PDA; imaging; congenital
INTRODUCTION
CASES
Interventional closure of the patent ductus arteriosus (PDA) requires accurate anatomic assessment including definition of ductal morphology and caliber. Angiography is the gold standard, but can have limitations. We report here the first known uses of optical coherence tomography (OCT) in congenital heart disease, during ductal occlusion in two patients. This was done to assess the feasibility of OCT in children and in patients with congenital heart disease, as well as to assess its utility in imaging the PDA.
OCT (Dragonfly Duo OCT Imaging Catheter and ILUMIEN Optis OCT system, St. Jude Medical, St. Paul, MN) was used for anatomic definition of two PDAs during catheterization before interventional closure. The first was a 17-kg 5-year-old female with a moderate-sized pressure-restrictive PDA. Hemodynamic data demonstrated normal pulmonary pressures and an estimated pulmonary-to-systemic flow ratio of 1.6:1. Standard angiography demonstrated a coneshaped PDA with a minimal ductal diameter of
Additional Supporting Information may be found in the online version of this article.
*Correspondence to: James Hill, MD, Division of Pediatric Cardiology, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail: [email protected]
Division of Pediatric Cardiology, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, Cleveland, Ohio Conflict of interest: Nothing to report. Disclosures: None. C 2014 Wiley Periodicals, Inc. V
Received 14 February 2014; Revision accepted 1 October 2014 DOI: 10.1002/ccd.25690 Published online 8 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
OCT in Congenital Heart Disease
2.6 mm (Fig. 1A). A 5 Fr guide catheter was inserted into the femoral artery and advanced retrograde into the ductal ampulla. A 0.01400 wire was advanced through the PDA into the proximal main pulmonary artery, and the OCT catheter was advanced over this wire through the ductus. A 5-ml hand contrast injection was performed through the guide catheter to remove the blood and avoid attenuation of the infrared light while OCT pullback imaging at 20 mm/s was performed, giving a high-resolution three-dimensional representation of the ductus (Fig. 1B and C; accompanying Movie 1 in Supporting Information). This showed an ellipse-shaped orifice of the ductus, measuring 2.2 3.1 mm in the narrowest segment. Device choice was based on the angiographic measurement (usually 1–2 mm larger than the minimal ductal diameter), and a 6/4 Amplatzer Ductal Occluder (ADO; St. Jude Medical, St. Paul, MN) was inserted. Upon mild manipulation before release, however, the device slipped through the duct into the main pulmonary artery. The device was withdrawn, and upsized to an 8/6 ADO. This device was delivered without complication, and remains in place at last follow-up without residual shunt or any flow perturbation in the surrounding vessels. The second case was a 12-kg 2-year-old male with a small but audible PDA. Hemodynamic data showed normal pulmonary pressures with minimal saturation step-up from the mixed venous to the left pulmonary artery. A standard angiogram demonstrated a small tube-shaped PDA with a minimal diameter of 1.4 mm (Fig. 1D). A 4 Fr guide catheter and 0.01400 wire were advanced from the femoral artery in a similar fashion as the first patient. However, to spare upsizing the sheath in the femoral artery and to test performing the OCT pullback in the same direction as blood flow (from aorta to pulmonary artery), the 0.01400 wire was snared in the main pulmonary artery and externalized through the femoral vein. This created an arteriovenous rail, allowing a 6 Fr guide catheter to be advanced over the wire from the femoral vein and to the pulmonary artery in an antegrade fashion. From there, the OCT catheter was advanced over the wire through the PDA for imaging. Contrast injection was performed into the ampulla through a 4 Fr end-hole catheter through the femoral artery over the wire. The threedimensional OCT image showed a tubular PDA with a mildly asymmetric narrowest ductal segment measuring 1.6 2.3 mm (Fig. 1E and F; accompanying Movie 2 in online Supporting Information). Again, device was chosen based on the angiographic measurements and a 3-mm diameter coil was deployed successfully within the ductus (usually 2 minimal ductal diameter). At
279
latest follow-up, the coil remains in position with no residual shunt or flow perturbation in the surrounding vessels.
DISCUSSION
Angiography has been the “gold standard” for PDA imaging prior to percutaneous device closure. Although angiography provides sufficient guidance in most cases, it also can have limitations. First, the patient is subjected to radiation and contrast, which can be detrimental to children [1]. Second, measurement of ductal morphology can be imprecise because of limited resolution, projection of anatomy in only one or two planes, and because of overlapping opacified pulmonary arteries or aorta. OCT is currently used to evaluate the threedimensional and cross sectional structure of atherosclerotic vessels [2]. It uses near infrared light ( 1.3 mm) from a small lens at the tip of the catheter, which rotates giving cross sectional images and threedimensional reconstructions at resolution down to 10–15 lm [3]. We are evaluating OCT for a potential role in children and in congenital heart disease because of its superior resolution and three-dimensional capabilities, as well as for its potential to decrease radiation dosage. In these two cases, we made a specific point not to alter normal practices by selecting occlusion devices based on standard angiography. However, we believe the OCT imaging gave a more complete assessment of ductal anatomy and, in both cases, may have led to choosing a larger device than what was chosen based on angiography. In the first case, the minimal ductal diameter of 2.6 mm by angiography led to a choice of a device with narrowest portion of 4 mm (device usually 1–2 mm larger than narrowest PDA diameter). Based on the OCT images, the narrowest portion of the ductus was elliptical and measured 2.2 3.1 mm. As placing a round device within an ellipse necessitates either over-sizing it in one dimension or undersizing it in the other, the practice leading to fewer device embolizations and less residual shunt would likely be sizing the device based on the maximum dimension at the narrowest location. The OCT measurement of 3.1 mm at that location would have probably resulted in using an 8/6 ADO, which was the device that was eventually deployed successfully. In the second case, the minimal ductal diameter of 1.4 mm by angiography led to using a 3 mm coil (usually coil diameter chosen is twice the minimal ductal diameter). However, as the OCT again showed an elliptical shape of 1.6 2.3 mm at the narrowest diameter, a 4 mm coil probably would have been chosen. As there is some leeway in device selection, the 3 mm coil ended up with
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
280
Hill et al.
Fig. 1. A: Still frame from a straight lateral angiogram shows the patent ductus arteriosus from patient #1 profiled, with significant overlap of contrast in both the ascending aorta and the main pulmonary artery. The minimal diameter measured 2.6 mm. B and C: Still frames from the OCT three-dimensional reconstruction of patient #1 shows the patent ductus arteriosus in long and short axes. The lumen is not circular in shape, and in fact measured 2.2 3 3.1 mm2 at the narrowest point. D: Still frame from a straight lateral angiogram shows a profile of a small tubular-shaped patent ductus arteriosus in patient #2, with the narrowest portion measuring 1.4 mm. E and F:
Still frames from the OCT three-dimensional reconstruction of patient #2 show the patent ductus arteriosus in long and short axes, with minimal lumenal measurements of 1.6 3 2.3 mm2. For all OCT visualizations and reconstructions, the raw data was exported to a custom Matlab (MathWorks, Natick, MA) program, processed and visualized in Amira (Visualization Science Group, Burlington, MA). The raw data can also be processed directly within the ILUMIEN Optis system, which gives real-time three-dimensional automatic reconstructions.
successful closure despite being only 130% the maximal narrow dimension by OCT. Although device embolizations are relatively rare during PDA closures, most experienced interventionalists have had this occur. It is unknown, although certainly feasible, whether more complete anatomic definition with OCT would lead to fewer device embolizations and perhaps fewer residual shunts. Unfortunately, there are also several limitations to the use of OCT for imaging the PDA. First, the PDA is a high-velocity vessel that makes complete opacification somewhat difficult due to rapid clearance of contrast. Second, any manipulation within the PDA can cause the vessel to spasm leading to incorrect measurements. Angiography is usually performed before any instrumentation occurs within the PDA, but OCT requires catheter passage through the region of interest before imaging. Although we did not note ductal spasm in either of our cases, the possibility of this causing inaccurate measurements would remain a concern. Third, OCT imaging is limited to the vessel itself, and does not include the aorta or the pulmonary artery, which are often important factors that need to be taken
into account when choosing the proper occlusion device. As ductal occlusion is a relatively straight-forward and low-risk procedure with a high degree of success and low rate of complications, OCT would have to be shown to be superior in anatomical accuracy as well as be widely available, cheap, and easy to use without adding significant risk. At the present time, it is neither widely available in congenital catheterization laboratories nor is it cheap (although our equipment was without cost in these cases). It is fairly straightforward to use with a short learning curve, although we were certainly helped by our adult cardiologists’ significant OCT experience. Image acquisition occurs real-time, and the automated 3-D reconstruction occurs within seconds. In our experience, there were only minor alterations necessary to the automated process, and the whole 3-D reconstruction took no longer than 2–3 min. For the purpose of publication, we exported the raw data to a separate processing program but this is not otherwise necessary. The OCT added a small amount of time and contrast to our procedures, although this was not significant and would not be
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
OCT in Congenital Heart Disease
necessary were we to adopt this procedure exclusively. The final limitation is that OCT in its current form requires a 5–6 Fr guide catheter, whereas many PDA occlusions can otherwise be performed through only a 4 Fr sheath.
281
They also greatly appreciate the support of our division chief, Christopher Snyder, MD. REFERENCES 1. Modan B, Keinan L, Blumstein T, Sadetzki S. Cancer following cardiac catheterization in childhood. Int J Epidemiol 2000;29: 424–428.
CONCLUSIONS
We found OCT imaging of the PDA to be feasible, and only used a small amount of additional radiation and contrast (standard angiography was also performed to compare techniques). We feel that the threedimensional OCT reconstructions provided significant additional anatomic information that could potentially improve device selection. In addition, once the technique is perfected, little or no angiography or fluoroscopy would be required to perform imaging runs, and only a small injection of contrast appears to be sufficient for vessel imaging. However, there are certain limitations to OCT imaging at this time that are unlikely to make it the method of choice specifically for imaging the patent ductus arteriosus, but we have shown its ability to provide high resolution imaging in congenital heart disease. ACKNOWLEDGMENTS
The authors want to acknowledge the OCT clinical expertise of both Marco Costa, MD, PhD, and Hiram Bezerra, MD, PhD, and appreciate their guidance.
2. Stefano GT, Bezerra HG, Mehanna E, Yamamoto H, Fujino Y, Wang W, Attizzani G, Chamie D, Simon DI, Costa MA. Unrestricted utilization of frequency domain optical coherence tomography in coronary interventions. Int J Cardiovasc Imaging 2013;29:741–752. 3. Tearney GJ, Regar E, Akasaka T, Adriaenssens T, Barlis P, Bezerra HG, Bouma B, Bruining N, Cho JM, Chowdhary S, Costa MA, de Silva R, Dijkstra J, Di Mario C, Dudek D, Falk E, Feldman MD, Fitzgerald P, Garcia-Garcia HM, Gonzalo N, Granada JF, Guagliumi G, Holm NR, Honda Y, Ikeno F, Kawasaki M, Kochman J, Koltowski L, Kubo T, Kume T, Kyono H, Lam CC, Lamouche G, Lee DP, Leon MB, Maehara A, Manfrini O, Mintz GS, Mizuno K, Morel MA, Nadkarni S, Okura H, Otake H, Pietrasik A, Prati F, Raber L, Radu MD, Rieber J, Riga M, Rollins A, Rosenberg M, Sirbu V, Serruys PW, Shimada K, Shinke T, Shite J, Siegel E, Sonoda S, Suter M, Takarada S, Tanaka A, Terashima M, Thim T, Uemura S, Ughi GJ, van Beusekom HM, van der Steen AF, van Es GA, van Soest G, Virmani R, Waxman S, Weissman NJ, Weisz G, International Working Group for Intravascular Optical Coherence Tomography (IWG-IVOCT). Consensus standards for acquisition, measurement, and reporting of intravascular optical coherence tomography studies: A report from the International Working Group for Intravascular Optical Coherence Tomography Standardization and Validation. J Am Coll Cardiol 2012;59: 1058–1072.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Optical Coherence Tomography Imaging of the Patent Ductus Arteriosus: First Known Uses in Congenital Heart Disease James A. Hill,* MD, Guruprasad Mahadevaiah, MD, and Michael W. Jenkins, PhD Background: Angiography is used to assess ductal morphology and caliber during interventional closure of the ductus arteriosus. We are evaluating the use of optical coherence tomography (OCT) to evaluate ductal anatomy given the potential benefit of superior resolution and lower radiation. Methods: Standard angiograms were performed on two patients with patent ductus arteriosus prior to device occlusion. OCT was then used to obtain high-resolution three-dimensional vessel reconstructions. Devices were chosen based on angiographic measurements. Results: OCT resulted in excellent threedimensional anatomic definition, with elliptical narrowest lumenal measurements of 2.2 3 3.1 mm and 1.6 3 2.3 mm, respectively, compared with angiographic measurements of 2.6 and 1.4 mm. Conclusions: To our knowledge, this is the first reported use of OCT use in pediatric patients outside the coronaries, and in patients with congenital heart disease. We found OCT imaging of the PDA to be feasible, and only used a small amount of additional radiation and contrast. The three-dimensional OCT reconstructions provided additional anatomic information that could potentially improve device selection, and in both cases may have led to choosing larger devices than what was chosen based on angiography. In addition, once the technique is perfected, little or no angiography or fluoroscopy will be required to perform imaging runs, and only a small injection of contrast appears to be sufficient for vessel imaging. However, there are certain limitations to OCT imaging that are unlikely to make it the method of choice specifically for imaging the patent ductus arteriosus, but we have shown its ability to provide high resolution imaging in a relatively simple fashion which may prove useful for other purposes. VC 2014 Wiley Periodicals, Inc. Key words: OCT; PDA; imaging; congenital
INTRODUCTION
CASES
Interventional closure of the patent ductus arteriosus (PDA) requires accurate anatomic assessment including definition of ductal morphology and caliber. Angiography is the gold standard, but can have limitations. We report here the first known uses of optical coherence tomography (OCT) in congenital heart disease, during ductal occlusion in two patients. This was done to assess the feasibility of OCT in children and in patients with congenital heart disease, as well as to assess its utility in imaging the PDA.
OCT (Dragonfly Duo OCT Imaging Catheter and ILUMIEN Optis OCT system, St. Jude Medical, St. Paul, MN) was used for anatomic definition of two PDAs during catheterization before interventional closure. The first was a 17-kg 5-year-old female with a moderate-sized pressure-restrictive PDA. Hemodynamic data demonstrated normal pulmonary pressures and an estimated pulmonary-to-systemic flow ratio of 1.6:1. Standard angiography demonstrated a coneshaped PDA with a minimal ductal diameter of
Additional Supporting Information may be found in the online version of this article.
*Correspondence to: James Hill, MD, Division of Pediatric Cardiology, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106. E-mail: [email protected]
Division of Pediatric Cardiology, Rainbow Babies & Children’s Hospital, University Hospitals Case Medical Center, Cleveland, Ohio Conflict of interest: Nothing to report. Disclosures: None. C 2014 Wiley Periodicals, Inc. V
Received 14 February 2014; Revision accepted 1 October 2014 DOI: 10.1002/ccd.25690 Published online 8 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
OCT in Congenital Heart Disease
2.6 mm (Fig. 1A). A 5 Fr guide catheter was inserted into the femoral artery and advanced retrograde into the ductal ampulla. A 0.01400 wire was advanced through the PDA into the proximal main pulmonary artery, and the OCT catheter was advanced over this wire through the ductus. A 5-ml hand contrast injection was performed through the guide catheter to remove the blood and avoid attenuation of the infrared light while OCT pullback imaging at 20 mm/s was performed, giving a high-resolution three-dimensional representation of the ductus (Fig. 1B and C; accompanying Movie 1 in Supporting Information). This showed an ellipse-shaped orifice of the ductus, measuring 2.2 3.1 mm in the narrowest segment. Device choice was based on the angiographic measurement (usually 1–2 mm larger than the minimal ductal diameter), and a 6/4 Amplatzer Ductal Occluder (ADO; St. Jude Medical, St. Paul, MN) was inserted. Upon mild manipulation before release, however, the device slipped through the duct into the main pulmonary artery. The device was withdrawn, and upsized to an 8/6 ADO. This device was delivered without complication, and remains in place at last follow-up without residual shunt or any flow perturbation in the surrounding vessels. The second case was a 12-kg 2-year-old male with a small but audible PDA. Hemodynamic data showed normal pulmonary pressures with minimal saturation step-up from the mixed venous to the left pulmonary artery. A standard angiogram demonstrated a small tube-shaped PDA with a minimal diameter of 1.4 mm (Fig. 1D). A 4 Fr guide catheter and 0.01400 wire were advanced from the femoral artery in a similar fashion as the first patient. However, to spare upsizing the sheath in the femoral artery and to test performing the OCT pullback in the same direction as blood flow (from aorta to pulmonary artery), the 0.01400 wire was snared in the main pulmonary artery and externalized through the femoral vein. This created an arteriovenous rail, allowing a 6 Fr guide catheter to be advanced over the wire from the femoral vein and to the pulmonary artery in an antegrade fashion. From there, the OCT catheter was advanced over the wire through the PDA for imaging. Contrast injection was performed into the ampulla through a 4 Fr end-hole catheter through the femoral artery over the wire. The threedimensional OCT image showed a tubular PDA with a mildly asymmetric narrowest ductal segment measuring 1.6 2.3 mm (Fig. 1E and F; accompanying Movie 2 in online Supporting Information). Again, device was chosen based on the angiographic measurements and a 3-mm diameter coil was deployed successfully within the ductus (usually 2 minimal ductal diameter). At
279
latest follow-up, the coil remains in position with no residual shunt or flow perturbation in the surrounding vessels.
DISCUSSION
Angiography has been the “gold standard” for PDA imaging prior to percutaneous device closure. Although angiography provides sufficient guidance in most cases, it also can have limitations. First, the patient is subjected to radiation and contrast, which can be detrimental to children [1]. Second, measurement of ductal morphology can be imprecise because of limited resolution, projection of anatomy in only one or two planes, and because of overlapping opacified pulmonary arteries or aorta. OCT is currently used to evaluate the threedimensional and cross sectional structure of atherosclerotic vessels [2]. It uses near infrared light ( 1.3 mm) from a small lens at the tip of the catheter, which rotates giving cross sectional images and threedimensional reconstructions at resolution down to 10–15 lm [3]. We are evaluating OCT for a potential role in children and in congenital heart disease because of its superior resolution and three-dimensional capabilities, as well as for its potential to decrease radiation dosage. In these two cases, we made a specific point not to alter normal practices by selecting occlusion devices based on standard angiography. However, we believe the OCT imaging gave a more complete assessment of ductal anatomy and, in both cases, may have led to choosing a larger device than what was chosen based on angiography. In the first case, the minimal ductal diameter of 2.6 mm by angiography led to a choice of a device with narrowest portion of 4 mm (device usually 1–2 mm larger than narrowest PDA diameter). Based on the OCT images, the narrowest portion of the ductus was elliptical and measured 2.2 3.1 mm. As placing a round device within an ellipse necessitates either over-sizing it in one dimension or undersizing it in the other, the practice leading to fewer device embolizations and less residual shunt would likely be sizing the device based on the maximum dimension at the narrowest location. The OCT measurement of 3.1 mm at that location would have probably resulted in using an 8/6 ADO, which was the device that was eventually deployed successfully. In the second case, the minimal ductal diameter of 1.4 mm by angiography led to using a 3 mm coil (usually coil diameter chosen is twice the minimal ductal diameter). However, as the OCT again showed an elliptical shape of 1.6 2.3 mm at the narrowest diameter, a 4 mm coil probably would have been chosen. As there is some leeway in device selection, the 3 mm coil ended up with
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
280
Hill et al.
Fig. 1. A: Still frame from a straight lateral angiogram shows the patent ductus arteriosus from patient #1 profiled, with significant overlap of contrast in both the ascending aorta and the main pulmonary artery. The minimal diameter measured 2.6 mm. B and C: Still frames from the OCT three-dimensional reconstruction of patient #1 shows the patent ductus arteriosus in long and short axes. The lumen is not circular in shape, and in fact measured 2.2 3 3.1 mm2 at the narrowest point. D: Still frame from a straight lateral angiogram shows a profile of a small tubular-shaped patent ductus arteriosus in patient #2, with the narrowest portion measuring 1.4 mm. E and F:
Still frames from the OCT three-dimensional reconstruction of patient #2 show the patent ductus arteriosus in long and short axes, with minimal lumenal measurements of 1.6 3 2.3 mm2. For all OCT visualizations and reconstructions, the raw data was exported to a custom Matlab (MathWorks, Natick, MA) program, processed and visualized in Amira (Visualization Science Group, Burlington, MA). The raw data can also be processed directly within the ILUMIEN Optis system, which gives real-time three-dimensional automatic reconstructions.
successful closure despite being only 130% the maximal narrow dimension by OCT. Although device embolizations are relatively rare during PDA closures, most experienced interventionalists have had this occur. It is unknown, although certainly feasible, whether more complete anatomic definition with OCT would lead to fewer device embolizations and perhaps fewer residual shunts. Unfortunately, there are also several limitations to the use of OCT for imaging the PDA. First, the PDA is a high-velocity vessel that makes complete opacification somewhat difficult due to rapid clearance of contrast. Second, any manipulation within the PDA can cause the vessel to spasm leading to incorrect measurements. Angiography is usually performed before any instrumentation occurs within the PDA, but OCT requires catheter passage through the region of interest before imaging. Although we did not note ductal spasm in either of our cases, the possibility of this causing inaccurate measurements would remain a concern. Third, OCT imaging is limited to the vessel itself, and does not include the aorta or the pulmonary artery, which are often important factors that need to be taken
into account when choosing the proper occlusion device. As ductal occlusion is a relatively straight-forward and low-risk procedure with a high degree of success and low rate of complications, OCT would have to be shown to be superior in anatomical accuracy as well as be widely available, cheap, and easy to use without adding significant risk. At the present time, it is neither widely available in congenital catheterization laboratories nor is it cheap (although our equipment was without cost in these cases). It is fairly straightforward to use with a short learning curve, although we were certainly helped by our adult cardiologists’ significant OCT experience. Image acquisition occurs real-time, and the automated 3-D reconstruction occurs within seconds. In our experience, there were only minor alterations necessary to the automated process, and the whole 3-D reconstruction took no longer than 2–3 min. For the purpose of publication, we exported the raw data to a separate processing program but this is not otherwise necessary. The OCT added a small amount of time and contrast to our procedures, although this was not significant and would not be
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
OCT in Congenital Heart Disease
necessary were we to adopt this procedure exclusively. The final limitation is that OCT in its current form requires a 5–6 Fr guide catheter, whereas many PDA occlusions can otherwise be performed through only a 4 Fr sheath.
281
They also greatly appreciate the support of our division chief, Christopher Snyder, MD. REFERENCES 1. Modan B, Keinan L, Blumstein T, Sadetzki S. Cancer following cardiac catheterization in childhood. Int J Epidemiol 2000;29: 424–428.
CONCLUSIONS
We found OCT imaging of the PDA to be feasible, and only used a small amount of additional radiation and contrast (standard angiography was also performed to compare techniques). We feel that the threedimensional OCT reconstructions provided significant additional anatomic information that could potentially improve device selection. In addition, once the technique is perfected, little or no angiography or fluoroscopy would be required to perform imaging runs, and only a small injection of contrast appears to be sufficient for vessel imaging. However, there are certain limitations to OCT imaging at this time that are unlikely to make it the method of choice specifically for imaging the patent ductus arteriosus, but we have shown its ability to provide high resolution imaging in congenital heart disease. ACKNOWLEDGMENTS
The authors want to acknowledge the OCT clinical expertise of both Marco Costa, MD, PhD, and Hiram Bezerra, MD, PhD, and appreciate their guidance.
2. Stefano GT, Bezerra HG, Mehanna E, Yamamoto H, Fujino Y, Wang W, Attizzani G, Chamie D, Simon DI, Costa MA. Unrestricted utilization of frequency domain optical coherence tomography in coronary interventions. Int J Cardiovasc Imaging 2013;29:741–752. 3. Tearney GJ, Regar E, Akasaka T, Adriaenssens T, Barlis P, Bezerra HG, Bouma B, Bruining N, Cho JM, Chowdhary S, Costa MA, de Silva R, Dijkstra J, Di Mario C, Dudek D, Falk E, Feldman MD, Fitzgerald P, Garcia-Garcia HM, Gonzalo N, Granada JF, Guagliumi G, Holm NR, Honda Y, Ikeno F, Kawasaki M, Kochman J, Koltowski L, Kubo T, Kume T, Kyono H, Lam CC, Lamouche G, Lee DP, Leon MB, Maehara A, Manfrini O, Mintz GS, Mizuno K, Morel MA, Nadkarni S, Okura H, Otake H, Pietrasik A, Prati F, Raber L, Radu MD, Rieber J, Riga M, Rollins A, Rosenberg M, Sirbu V, Serruys PW, Shimada K, Shinke T, Shite J, Siegel E, Sonoda S, Suter M, Takarada S, Tanaka A, Terashima M, Thim T, Uemura S, Ughi GJ, van Beusekom HM, van der Steen AF, van Es GA, van Soest G, Virmani R, Waxman S, Weissman NJ, Weisz G, International Working Group for Intravascular Optical Coherence Tomography (IWG-IVOCT). Consensus standards for acquisition, measurement, and reporting of intravascular optical coherence tomography studies: A report from the International Working Group for Intravascular Optical Coherence Tomography Standardization and Validation. J Am Coll Cardiol 2012;59: 1058–1072.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
